At the operation, we usually encounter a singlelarge sac, completely walled off from the intestines; usually lying in the middle of the lower half of the abdomen—less often, laterally; and containing large quan tities of thick, creamy, greenish, yellowish green, or yellow, odorless pus, containing many flakes of fibrin. The appearance resembles thoracic empyema. The rapidly fatal cases present the picture of pneumococcus sepsis; in those which run a less rapid course, the puru lent exudate is diffused throughout the abdomen and there are few, or no, adhesions.
How do the pncunwrorci reach the peritoneal cavity? In a certain proportion of cases, infection must occur by way of the circulation. Miehaut, in fact, considers this to be the only path of infection. Con siderable evidence is extant that the cocci reach the peritoneum through the intestines or appendix (de Quervain). The frequent occurrence of the disease in girls naturally points to the genital tract as the starting point in 6011IC of the cases; whereas in others it is probable that the infective agent passes directly front the pleural to the peritoneal cavity through the diaphragm.
To illustrate the great. variety of conditions encountered, we may cite the fact that one of our patients, on the third day of the disease, showed, in addition to the symptoms of peritonitis, a pneumonic infil tration of the left upper lobe. In another, on the first clay of the disease, tonsillar angina and pleuritic friction were present. In a third case nephritis and pleurisy preceded the perit.onitis. The conception of an "idiopathic" peritonitis can no longer be maintained.
Treatment must be medical at first. As soon as the tentative diagnosis of acute peritonitis is made. absolute rest must be enjoined, especially complete rest of the intestinal tract. It is of special impor tance pneumococcus peritonitis, in which there already exists a tendency to wall off the exudate, to favor this process and prevent the inflammation from becoming general.
During the period of acute symptoms, the administration of food by the mouth must be absolutely forbidden, and the patients nourished by nutritive enemata and rectal injections of water. I hold the identical
views regarding the absolute importance of this measure that Sahli has expressed. Should the rectal injections not be retained, on account of irritability of the intestines, subcutaneous infusions of normal salt solution must be given, and are of great value.
Rest for the intestinal tract is secured by the uso of opium (the only drug of any service), in doses ranging from one to ten drops of the tincture opii according to the age of the child • or from one-twelfth to one-fourth of a grain of the extractum opii, repeated several times, until the pain ceases, when the drug should be withheld. Should the pain return, the cautious continuation of the treatment with opium in small (loses is necessary.
Locally, we Ilse the ice bag (partly filled to avoid pressure on the abdomen) Or iced compresses, whereby, as a rule, much relief is afforded. Should this not be the ease, lukewarm compresses may supply their place and prove grateful to the patient. The influence of local treat ment on the course of the disease is not definitely known. Leeches frequently afford much relief from pain, but their use inay be dispensed with unless the suffering is extreme. Purgatives are strictly interdicted, as well as intestinal irrigation; at least, in the early stages of the disease. As soon as an exudate develops, but no sooner, laparotomy must be performed.
The incision should be central, two to three inches long, below the navel. Drainage must be used. In the Jenner Hospital, we irrigate the abdominal cavity with normal salt-solution or Tavel's solution (71 per cent. sodium chloride and 21 per cent. calcined sodium carbonate); others omit irrigation. The results are excellent in the encapsulated form of the disease; in the general peritonitis, the results are better, the earlier the operation is performed. Without operation, the patient is exposed to the dangers: of septicremia. Should spontaneous rupture through the abdominal wall occur, the conditions are rarely favorable for drainage.